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Summary of the impact

Two major national studies, conducted by staff in the Unit and colleagues
from a number of other institutions, provide the most comprehensive
estimate to date of the prevalence of prescribing errors in general
practice in England. These studies identified a number of strategies for
reducing these prescribing errors that have been endorsed by the General
Medical Council (GMC). Other impacts from these studies include increased
public understanding and debate through media coverage, changes to GP
education to be implemented by the Royal College of General Practitioners
(RCGP), improvements to computerised prescribing decision support for
general practitioners and increased awareness of the medication safety
role of primary care pharmacists.

Underpinning research

The PINCER trial (2006-10) and the PRACtICe study (2010-11) were led by
Prof. Anthony Avery (University of Nottingham). Dr Rachel Howard
(Lecturer in Pharmacy Practice, University of Reading, appointed 2006) was
one of only two other co-applicants named on both study grant
applications. Other colleagues involved include:

The aim of the PRACtICe study was to determine the prevalence and nature
of prescribing errors in general practice; to explore the causes of these
errors; and to identify defences against errors. Despite the introduction
of electronic prescribing into UK general practice, medication errors
remain a significant problem, accounting for more than 4% of hospital
admissions. Prior to the PINCER trial there was no evidence for effective
strategies to reduce harm from medication errors in primary care.

The study used a mixed methods approach that included: two systematic
reviews, a retrospective review of unique medication items prescribed over
a 12 month period to patients from 15 general practices in England,
interviews with 34 prescribers regarding 70 potential errors, 15 root
cause analyses, and six focus groups involving 46 primary health care team
members.

The study involved examination of 6,048 unique prescription items for
1,767 patients (2% of patients registered with participating general
practices).Prescribing or monitoring errors were detected for one in eight
patients, involving 5% of all prescription items. Most of the errors were
of mild to moderate severity, with one in 550 items being associated with
a severe error.

In 2011, 933.2 million prescription items (excluding dressings and
appliances) were dispensed in England1. Therefore, the error
rates identified in the PRACtICe study could equate to 46.6 million
prescription items with errors and 1.7 million prescription items with
severe errors that could result in death or permanent disability. The
proportion of errors that result in negative outcomes is currently
unknown, but medication errors are estimated to cause approximately 4%2
of non-elective hospital admissions. If these could be reduced by 50%
through changes to prescribing practices in primary care then 106,000
hospital admissions could be avoided (based on 5.3 million emergency
admissions in England 2010-11)3. The cost of a hospital
admission has been estimated to be between £1993 and £31814;
therefore, the cost savings to the UK National Health Service (NHS) of
avoiding these admissions could be as much as £337.2 million per year.

The following factors were associated with increased risk of prescribing
or monitoring errors in the PRACtICe study: male gender of patient, age of
patient less than 15 years or greater than 64 years, number of unique
medication items prescribed and being prescribed preparations in specified
therapeutic areas, such as cardiovascular disease or infections.
Prescribing or monitoring errors were not associated with the grade of GP
or whether prescriptions were issued as acute or repeat items.

A wide range of underlying causes of error were identified. In
particular, a lack of focus on therapeutics and safe prescribing skills in
GP training was highlighted. In addition, deficiencies were found in the
design of computerised prescribing systems in general practices. Also,
general practices did not have reliable systems for detecting and
correcting errors once they had occurred.

Strategies that were identified for reducing prescribing errors in
general practice include improvements to GP training, improvements to GP
computer systems and the introduction of better systems for detecting and
correcting errors (as demonstrated in the PINCER trial).

The aim of the PINCER trial was to determine the effectiveness,
costs/benefits and acceptability of a pharmacist-led IT-based intervention
compared with simple feedback in reducing rates of potentially hazardous
prescribing and medicines management in general practice.

PINCER was a cluster-randomised controlled trial that incorporated a
health economic analysis, embedded longitudinal qualitative analysis and
process analysis of pharmacists' interventions. The control group of
general practices received simple computer-generated feedback for patients
at risk of hazardous prescribing, while the intervention group received
feedback, educational outreach and dedicated support from a pharmacist.

Seventy-two general practices were randomised. At 6 months follow-up,
patients in the intervention group were significantly less likely to have
received one of three types of potentially hazardous prescription (such as
patients with asthma who had been prescribed a beta-blocker). If decision
makers are willing to pay up to £75 over a 6 month period in order to
avoid an error, then PINCER has a 95% probability of being cost effective.
As it was effective for all types of error and all examples of error which
could be operationalised, it is reasonable to expect that the intervention
would be transferable to other prescribing errors. Also, since the trial
included a range of practice types (single-handed through to large
practices) in a range of areas (urban through to rural) it is also
reasonable to assume that the intervention would be transferable to other
practices.

The Health and Social Care Information Centre. Prescriptions dispensed
in the community 2001-2011. Available from www.hscic.gov.uk

Avery A et al. Investigating the prevalence and causes of prescribing
errors in general practice: The PRACtICe Study (PRevalence And Causes of
prescrIbing errors in general practiCe). London: General Medical Council,
2012. (259-page project report). Report available at: http://www.gmc-uk.org/about/research/12996.asp

The PINCER trial grant (Sponsor: Dept. of Health; value £643,690;
2006-2010, CT4086) was awarded to Prof. Avery with Dr Rachel Howard as a
named co-applicant.

Details of the impact

The GMC-funded PRACtICe study has provided the best evidence to date on
the prevalence, nature and causes of prescribing errors in general
practices, while the PINCER trial has produced one of the only successful
interventions to reduce prescribing errors in primary care. Before the
PRACtICe study, the existing estimate of prevalence and type of
prescribing errors in General Practice was: Shah et al. A survey of
prescription errors in general practice. Pharm J 2001; 267: 860-2. This
study is both out of date (it pre-dates the wide-spread adoption of
electronic prescribing in general practice) and did not use the gold
standard methodology used in the PRACtICe study. As a result,
recommendations arising from the PRACtICe study are supported by the GMC
and have been taken up by organisations including the RCGP and TPP, a
major supplier of GP computer systems.

The PRACtICe study report was launched at a major press conference at the
Wellcome Trust on 1st May 2012. The findings of the study
received substantial media coverage a, including two
front-page headlines (The Daily Telegraph and The Daily Express)
and articles in all the major national newspapers, radio coverage on
several hundred radio stations and web coverage on several hundred
websites. Dr Howard was interviewed by Heart Thames Valley Radio,
and has ongoing contact with BBC Radio Berkshire who continue to be
interested in the progress made in developing safeguards. Prof. Avery was
interviewed on the BBC Radio 4 Today Programme and BBC Radio 2 Jeremy Vine
show, and Prof. Rubin (President of the GMC) appeared on the BBC One
Breakfast TV programme. This coverage, and in particular the interviews,
raised public awareness and debate around the problems of prescribing
errors in general practice and helped to enhance public understanding of
the issue. An article in the Daily Mail also explained what
patients can do to help reduce their chances of experiencing a prescribing
error. Dr Howard delivered an invited lecture in July 2013 to 150
non-medical prescribers on lessons to be learned from both PRACtICe and
PINCER, further increasing dissemination of the results to a wider body of
healthcare professionals.

The PRACtICe study report has clearly influenced the GMC b,
which has discussed the outcomes of the research with organisations that
have a remit for quality assurance (including other professional and
systems regulators), patient safety and the provision of medical education
and training. This has included the RCGP and General Pharmaceutical
Council. The study team have influenced the RCGP by working closely with
them and presenting the PRACtICe study findings and recommendations at a
RCGP Curriculum Group meeting in June 2012. As a result, the following
changes are taking place:

(1) Additional learning outcomes are being added to the RCGP curriculum cwith
respect to therapeutics and safe prescribing skills; these were
ratified by the GMC and were implemented in August 2013;

(2) eLearning packages have been developed and are expected to be
launched in December 2013. They will be supported by a series of articles
in INNOvait d, the journal of GP registrars;

(3) The assessment of therapeutics and safe prescribing skills is being
strengthened in the Membership of the Royal College of General
Practitioners examination.

Indicators of hazardous prescribing developed for the PINCER trial have
been available to general practices across England through Primary Care
Information Services since February 2013. So far, the PINCER trial
indicators have been downloaded by 800 general practices. The trial has
significantly influenced policy development at the Department of Health e.

The PRACtICE report suggested various ways in which prescribing safety
features of GP computer systems could be improved. A number of changes
have been introduced into the very widely used SystmOne GP
computer system (TPP) as a direct consequence of the PRACtICE findings f.

The main beneficiaries of the impact of both studies are GPs, both
individually and via their representative bodies (RCGP and GMC), practice
pharmacists (who have access to the PINCER trial indicators to help
facilitate their medicines safety roles) and ultimately patients. The
changes to the RCGP training programmes and examinations, in particular,
will help reduce the likelihood of medication errors reaching patients in
the primary care setting. The main evidence to date of the extent of the
impact described is from media coverage, changes being made to the RCGP
curriculum, nation-wide release of the PINCER query library g
and changes that have been made to the SystmOne GP computer
system. These impacts have occurred in 2012-13.

Sources to corroborate the impact

a. The research was showcased in many media outlets including The
Guardian, The Times, The Daily Express, Radio 4, etc. A summary of media
reports is available upon request.

b. Letter from Chair of the General Medical Council about impact of
PRACtICe study on GMC (*)

c. RCGP changes to curriculum and assessments can be found on http://bit.ly/1g3xFU1
and http://bit.ly/1asCqSg and
evidence of the influence of the PRACtiCE study on those changes can be
found in the minutes of the 18th meeting of RCGP Curriculum
Development Group (*)